Treatment of Dengue Ascites
The treatment of dengue ascites requires careful fluid management with isotonic crystalloid solutions as first-line therapy, with colloids reserved for cases of severe shock unresponsive to initial crystalloid resuscitation. 1, 2
Assessment and Classification
- Assess for warning signs of severe dengue including clinical fluid accumulation (ascites, pleural effusion), persistent vomiting, abdominal pain/tenderness, mucosal bleeding, lethargy/restlessness, liver enlargement, and rising hematocrit with concurrent thrombocytopenia 2
- Monitor for signs of shock, including tachycardia, hypotension, poor capillary refill, and altered mental status 3
- A rise in hematocrit of 20% along with a continuing drop in platelet count is an important indicator for the onset of shock 4
Fluid Management for Dengue Ascites
- For patients without shock but with ascites, oral rehydration is recommended as the first line of treatment 1
- Avoid routine use of bolus intravenous fluids in patients with ascites who are not in shock 5, 1
- For patients with dengue shock syndrome and ascites, administer an initial fluid bolus of 20 mL/kg of isotonic crystalloid solution (such as normal 0.9% saline or Ringer's lactate) 1, 6
- Crystalloids are the initial fluid of choice for most patients with dengue ascites 7
- If patients are not responsive to crystalloids despite adequate resuscitation, consider switching to colloid solutions 8
- For severe dengue shock syndrome with massive plasma leakage, colloid solutions may be beneficial when available 1, 6
Monitoring Parameters
- Perform frequent monitoring of vital signs and hematocrit levels to evaluate treatment response 4
- Watch for clinical indicators of adequate tissue perfusion, including normal capillary refill time, absence of skin mottling, warm and dry extremities, well-felt peripheral pulses, return to baseline mental status, and adequate urine output 1
- Be vigilant during the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 3, 2
- Daily complete blood count monitoring is essential, particularly to track platelet counts and hematocrit levels 1
Management of Complications
- Avoid drainage of ascites if possible, as it can lead to severe hemorrhages and sudden circulatory collapse 4
- For patients with persistent tissue hypoperfusion despite adequate fluid resuscitation, vasopressors such as dopamine or norepinephrine may be required 1, 8
- Blood transfusion may be necessary in cases of significant bleeding 1
- Prophylactic platelet transfusion is not recommended 7
Common Pitfalls to Avoid
- Avoid administering excessive fluid boluses in patients without shock, as this can lead to fluid overload and respiratory complications 1
- Avoid NSAIDs and aspirin due to increased bleeding risk 1, 2
- Avoid failing to recognize the critical phase when plasma leakage can rapidly progress to shock 1
- Avoid delaying fluid resuscitation in patients with dengue shock syndrome 1
- After stabilizing hemodynamics and clinical improvement, carefully reduce and discontinue fluid to avoid congestion and other complications 8
Special Considerations
- Polyserositis (pleural effusion and ascites) is common in dengue shock syndrome 4
- Secondary hemophagocytic lymphohistiocytosis is a potentially fatal complication that may require specific management with steroids or intravenous immunoglobulin 7
- Early recognition and treatment of shock is the key prognostic factor 4, 9